Despite a large body of scientific evidence, primary prevention of sudden cardiac arrest remains a clinical challenge. The extent of incorporation of medical advances in practice remains unknown. We sought to evaluate how MADIT II (the second Multi-center Automatic Defibrillator Implantation Trial) findings were utilized in retrospective manner.
Guthrie Healthcare System is a large multidisplinary organization serving 500,000 patients in a primary service area of seven counties and comprises of 228 physicians. We evaluated all echocardiograms performed between October 2003 (beginning of reimbursement by CMS for MADIT II criteria) to October 2004. Using ICD codes, patients with cardiomyopathy, ischemic heart disease, and heart failure were identified. This group was further stratified for MADIT II criteria. Medical records were evaluated for presence/absence of heart failure, presentation with clinical arrhythmias, events leading to implantation of devices, QRS morphology and duration, screening by individual physicians (including holter monitors, event monitors), and clinical referrals to electrophysiology services.
A total of 3538 echocardiograms were performed between October 2003 and October 2004. Of these, 591 patients were identified to have cardiomyopathy and heart failure, 109 patients met MADIT II criteria. Thirty-one patients (28.4%) received ICD implant. Of these, 27 patients received biventricular ICD and 4 patients received biventricular pacemaker. Twenty-nine patients had either spontaneous or inducible ventricular tachycardia. Solely based on MADIT II criteria, only 2 patients were referred for procedure as an out-patient by their primary care physician; 29 patients were identified during routine follow-up or hospitalization.
Despite widely published findings and efforts to educate primary care physicians, only a small percentage of patients who fulfill MADIT II criteria were referred for ICD implantation.
In the light of recently published guidelines by CMS for implantation of defibrillator without electrophysiology studies, further education for primary care physicians is necessary.
Pramod Deshmukh, None.